الفهرس 
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Abstract
Summary
Autism spectrum disorders (ASD) are a diverse group of conditions. They are characterized by difficulty with social interaction and communication. Other characteristics are atypical patterns of activities and behaviors, such as difficulty with transition from one activity to another, a focus on details and unusual reactions to sensations (Hyman, Levy & Myers, 2020).
Family caregivers of these children have to spend much energy and patience in managing the child’s behavioral, emotional and health problems. So they appear to be at great risk for depression, stress, anxiety and distress (Bravo-Benítez et al., 2019).
Stress is a natural feeling of not being able to cope with specific demands and events. However, stress can become a chronic condition if a person does not take steps to manage it (Barroso, Mendez, Graziano & Bagner, 2018). Therefore, when the stress level is high among family caregivers, this leads to an increase in level of expressed emotions, which negatively affects the pathological development of the autistic child.
Wherefore expressed emotions (EE) refers to the quality of the family environment reflected in the comments, attitudes and communication style of a relative about an individual. It might also be used as a means of examining the emotional climate that is likely to be experienced by family members in particular. Also, it is a measure of the affective relationship between two people in terms of criticism, hostility, and emotionally over-involved attitudes, positive remarks and warmth (Wang et al., 2023).
As well as family Caregivers require knowledge, skills, and judgment to carry out the tasks of care for children, and caregivers who feel prepared to deliver care (i.e., have the knowledge and skills needed) have less stress. As a result, they need to be provided with counseling interventions that comprise systemic, didactic-psychotherapeutic interventions that are adequate for informing family caregivers about the illness and its treatment to be able to cope with the burden of care (Yadava, Hooda & Sharma, 2016).
Nurses are in a great position to offer counsel and emotional support. The nurse can create an effective counseling intervention to help these family careers manage stress and reduce expressed emotions (Tiner et al., 2021).
Aim of the study
The study aimed to evaluate the effect of counseling intervention on stress and expressed emotions among family caregivers of children with autism.
The aim of this study was achieved through the following objectives:
1- Assessing stress among family caregivers of children with autism.
2- Assessing expressed emotions among family caregivers of children with autism.
3- Developing and implementing a counseling intervention for family caregivers of children with autism.
4- Evaluating the effect of the counseling intervention on stress and expressed emotions among family caregivers of children with autism.
Research Hypothesis:
Counseling intervention will have a positive effect on reducing stress and expressed emotions among family caregivers of children with autism.
Research Design
This study is a quasi-experimental (one group pre-post test).
Research Setting:
This study was conducted in outpatient clinics for autism in pediatric hospital affiliated with Ain Shams University Hospitals.
Subjects of the study:
A purposive sample of 40 family caregivers of children with ASD who agreed to participate in the study and fulfilled the following criteria:
Inclusion criteria for children with autism:
1- Child diagnosed with autism.
2- Age: Preschool and school age children (3-12years).
3- Sex: Both sex (males and females).
4- Free from other neurological or psychiatric diseases or handicapped.
5- Attended the previously mentioned setting regularly.
Inclusion criteria for family caregivers of children with autism:
1- Family members who give direct care to the child.
2- Sex: Both sex (males and females).
3- Free from any psychiatric illness.
4- Willing to participate in the study.
D-Tools of data collection: -
1- Socio-Demographic Interviewing Questionnaire.
It was designed by the researcher in a simple Arabic way after reviewing related literature and it included two parts:
A- First part: included data related to socio-demographic characteristics of family caregivers such as age, gender, marital status, and so on.
B- Second part: included data related to socio-demographic characteristics of children with autism such as gender, number of siblings, level of education, and so on.
2- The expressed emotions questionnaire
It was developed by Cole and Kazarian (1988) and adapted by the researchers to assess the levels of expressed emotions among family caregivers of children with autism. It consisted of five domains (Hostility, criticism, over-involvement, warmth and positive regard), which are represented at 47 statements, and it is based on three points liker scales (always, sometimes, and never). The scoring system was designed as follows: (3) for always, (2) for sometimes, and (1) for never. The total scores were classified as low expressed emotions if the score was less than 98 and high if the score ranged from 98 to 141.
3-Parenting stress index (PSI):
It was originally developed by Abidin [13] as a measure of parenting stress and was later modified to assess the stress faced by family caregivers of children with autism. It consists of three parts: parental distress, difficult child characteristics, and parent-child dysfunctional interactions. Parental distress includes 11 items, difficult child characteristics include 11 items, and parent-child dysfunctional interactions include 12 items.
The scale is composed of 34 questions and is based on a three-point Likert scale (agree, not sure, and disagree). The scoring system is designed as follows: (3) for agree, (2) for not sure and (1) for disagree. Total scores are categorized as mild stress if the score ranges from 34 to 57, moderate stress if it ranges from 58 to 81, and severe stress if the score is 82 or more.
Counseling intervention:
A Counseling intervention was provided to reduce the stress and expressed emotions among family caregivers of children with autism. It was designed by the researcher based on related recent literatures. It was written in a simple Arabic language and included two parts as the following:
Part I- Theoretical part:
It was concerned with knowledge about the needs of children with autism, the family caregiver’s role in caring for a child with autism, available services; reasons for family caregiver distress and ways of reducing stress and expressed emotions.
Part II- Practical part:
It focused on providing practical guidelines for dealing with child problems, the role of family caregivers in modifying the behaviors of children with autism, effective methods for managing stress and reducing expressed emotions, enhancing self-esteem, anger management, ways of expressing emotions, time management, and performing various relaxation techniques.
The counseling intervention consisted of 16 sessions, totaling 13 hours: 4 hours of theory and 9 hours of practical application. By the end of the program, family caregivers of children with autism acquired the necessary knowledge and skills to effectively reduce stress and expressed emotions.
The study findings were as the following:
• Concerning socio demographic data, the study revealed that more than three-quarters (77.5%) of family caregivers’ under study are female, and their consanguinity to children with autism was their mothers; nearly two-thirds of them (65%) their age was between 35 and less than 55 years old. With a mean age of 40.32±3.99. In relation to their marital status, it was found that most of them (92.5%) are married, and more than half of them (55.5%) are at the secondary level of education. In addition to their occupation, nearly two-thirds (65%) of family caregivers are working, and most of them (80%) residing in urban areas. Besides, more than one tenth of them (12.5%) have a positive family history of autism, and less than two-thirds (60% )their consanguinity to children with autism are brothers.
• As regards total stress, more than half (57.5%) of the studied family caregivers have severe stress at pre- implementation of counseling intervention, compared to one quarter of them (26%) post implementation of counseling intervention.
• As regards total levels of expressed emotions most ( 80%) of the studied family caregivers have highly expressed emotions at pre- implementation of counseling intervention compared to less than one third (32.5%) post implementation of counseling intervention.
• There were highly statistical significant positive correlation between total stress and total expressed emotions of family caregivers in pre and post implementation of counseling intervention.
Conclusion
In the light of the current study results, it can be concluded that, The implementation of counseling interventions for family caregivers of children with autism had a positive effect on reducing their stress regarding parental distress, parent-child dysfunctional interactions, difficult child characteristics, and expressed emotions regarding hostility, criticism, over-involvement, warmth, and positive regard.
In the light of the study findings, the following recommendations were suggested:
- The establishment of counseling clinics for family caregivers caring for children with autism is needed to deal with their stress and inform them about coping strategies for dealing with their child.
- Periodic scientific seminars for nurses about strategies of effective coping and methods of enhancing expressed emotions for family caregivers of children with autism.
- Developing free educational resources about autism for parents, home, school, educators, and students through providing hotline services
- Future research should be focus on the effect of family expressed emotions on the children behavior and their progress.